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LONG'S KILBOURNE ROAD PHARMACY
FQHCLA372 CARETEAM PLUS, INC.
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Covered Entity Details
Entity Name
CARETEAM PLUS, INC.
Subdivision Name
Careteam + Family Health and Specialty Care
Type
Health Center Program Look-Alike
340B ID
FQHCLA372
Entity Address
100 Professional Park Dr
Conway, SC 29526-9260
Grant Number
LALCS31819
Participating Start Date
10/1/2018
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
LONG'S KILBOURNE ROAD PHARMACY
Pharmacy Address
D/B/A AVITA PHARMACY 1053
630 KILBOURNE RD
COLUMBIA, SC 29205-2827
Pharmacy Comments
Contract Details
Approval Date
7/24/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Johanna Haynes, Executive Director
(843) 234-8220
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
7/11/2018
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